BILE DUCT INJURY/STRICTURE-PREVENTION AND MANAGEMENT

DR KSM BAPELA

• THE BEST CURE IS PREVENTION…….

Predictors of a difficult lapchole (pre-op)

• Gender: Male sex
• Age: older age>50
• BMI: obesity
• Medical history: prev acute cholecystitis

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• PRE OPERATIVE IMAGING (U/S OR CT)
• GB wall: thickened wall > 4-5mm
• Stones: impacted stones in GB neck
• Ducts : dilated CBD
• GB appearance : shrunken, contracted or fibrotic appearance

Intra operative findings

Why is this important??

Why do bile duct injuries occur

Preventative strategies to avoid injury

• 1. critical view of safety ( three criteria required)
• Hepatocystic triangle is cleared of fat and fibrous tissue
• The lower 1/3 of the GB is separated from the liver to expose the cystic plate (avascular plane), also known as liver bed of GB and lies in GB fossa
• Two and only two structures should be seen entering the GB ( cystic duct and artery)

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• 2. consider intra operative TIME OUT during laparoscopic cholecystectomy prior to clipping, cutting or transecting any ductal structures

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• intra operative time out should consist of a stop point in the operation to confirm that the critical view of safety has been achieved utilizing the double view
• Photographic evidence ( litigation)

• 3. Understand the potential for aberrant anatomy in all cases

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• Aberrant anatomy may include short cystic duct, aberrant hepatic ducts or a right hepatic artery that crosses anterior to the the common bile duct.

• 4. Make liberal use of cholangiography or other methods to image the biliary tree intra operatively

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• Cholangiography may be especially important in difficult cases or unclear anatomy from pre-operative imaging
• Selective vs routine angiography is an area of controvesy

• 5. Recognize when the dissection is approaching a zone of significant risk and halt the dissection before entering the zone

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• Failure to obtain adequate exposure of the anatomy of the hepatocystic triangle or when the dissection is not progressing due to bleeding , inflammation or fibrosis

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• Consider laparoscopic subtotal cholecystectomy and/or conversion open procedure

• 6. Get help from another surgeon when the dissection or conditions are difficultd

Anatomical landmarks for safe Lapchole

• Aid the surgeon towards safer areas of dissection, when identified correctly , minimize the risk of ductal injury ( B-SAFE landmarks)
• Calot’s triangle: For the dissection area, bordered by cystic duct, common hepatic duct, liver edge

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• Rouviere’s sulcus : A groove on the liver’s underside, usually containining the right posterior pedicle, reliably indicating the plane of the common bile duct

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• Cystic node: within Calot’s triangle, cystic artery mostly found behind it

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• Doudenum

Bile duct injury management ( Endoscopic vs Surgical)

• Immediate intra-operative
• Recognize injury and call for help
• If BDI is suspected ( bile leak, unexpected structure divided, bleeding)
• Stop further dissection and call an experienced surgeon for help

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.Cholangiography : perform IOC to map injury and Anatomy

.Bail out options

• Principle : repair not to be done by same surgeon who caused injury
• -simple repair: suture minor injuries or ligation, possibly over T-tube
• Drain and transfer patient for complex injuries, place a drain , control leak by clipping and transfer patient to specialized unit
• Avoid further dissection

Delayed ductal injury diagnosis

• Patient not following expected course of recovery
• DX MRCP / ERCP to define injury
• Initial management
• Drainage : place drains ( percutaneous or internal) to control bile leakage and prevent local infection
• ERCP/ Stent : for minor leaks or obstruction

Definitive Repair

• 6-8 weeks
• HPB : hepaticojejunostomy ( severe cases)
• For worse case senarios : partial hepatectomy or rarely liver transplant

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• KEY PRINCIPLES
• Early recognition and referral is crucial for good outcomes
• Avoid blind repair : prevents long term devastating outcomes
• Drainage: essential for controlling bile, creating controlled fistula and allowing for later repair

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Bile duct strictures

• Definition: A narrowing or blockade in a CBD impeding bile flow to intestines
• Common causes:
• Benign vs malignant
• Injury during surgery
• Inflammation: chronic pancreatitis, primary sclerosing cholangitis
• Gallstones
• Trauma
• Congenital : biliary atresia

Treatment

• Depends on grading/severity/ benign or malignant
• ERCP : Dilatation of stricture/ stent palacement (plastic or metal)/ to keep duct open post stone extraction
• Percutaneous transhepatic Cholangiography (PTC): drainage or stenting when ERCP fails
• Surgery for complicated strictures or malignancy

• Thank u